<html manifest="/static/cache.manifest">
  <head>
    <title>{{ title }}
  </head>
  <body>
  <h2>{{ title }}</h2>

  <p><em>Fields marked with '*' are required.</em></p>
  {% if errors %}
  <p><font color="red">Please correct errors marked in red</font></p>
  {% endif %}

  <form action="/add_proc" method="post">
  {% include "format_fields.html" %}

  <input type="hidden" name="pid" value="{{ pid }}"/>

  <hr>
  <h2>Additional patient information - pid {{ pid }}</h2>
  <div><input type="submit" name="add_proc" value="Go">&nbsp; Add another surgery or procedure</div>
  <div><input type="submit" name="add_problem" disabled value="Go">&nbsp; Add patient problem</div>
  <div><input type="submit" name="add_med" disabled value="Go">&nbsp; Add medication</div>
  <div><input type="submit" name="add_allergy" disabled value="Go">&nbsp; Add allergies</div>
  <div><input type="submit" name="add_test" disabled value="Go">&nbsp; Add test results</div>
  <p>
  <hr>
  <div><input type="submit" value="Continue >>"></div></p>

  </form>

  </body>
</html>
